SEMINAR ON

RECENT TRENDS
IN MANAGEMENT
OF BUERGERS
DISEASE
Chairperson Moderator
Dr. V.K. Raina Dr. Pawan Agrawal
Speaker
Dr. Sumeet Jaiswal
SPECIAL INVESTIGATIONS
1. Doppler ultrasound : Based on doppler effect. The
frequency shift is proportional to the velocity of the blood
flow. It may be analysed audibly and may be recorded
graphically. It gives quantitative information about the
degree of stenosis.
2. Plethysmography : Method of assessing changes in
volume due to arterial supply to that particular part.
Recently, segmental plethysmography has been
introduced by placing venous occlusion cuffs around the
thigh, calf and ankle. The cuffs are inflated to 65 mmHg
and the pulsation is the quantitative measure of the
arterial diseases.
3. Phonangiography – Vibrations of low frequently in the
arterial wall due to disturbances in blood flow can be
analysed audibly.
4. Isotope technique – Xenon 133 injected
Intramuscularly and its clearance is used
to study the blood flow in the calf muscles.
Recently technetium has become the
isotope of choice. Gamma camera is used
to picturise the blood flow in a limb.
5. Arteriography : Most reliable method. Gives

information about the size of the lumen, the

course, constriction and dilatation of the arteries

and collateral circulation. Hypaque 45 (sodium

diatrizoate) is the contrast medium often used.

Method generally used : Retrograde percutaneous

catheterization.
Retrograde percutaneous catheterization -

Needle and a cannula are introduced into common

femoral artery. Dangers (i) iodine sensitivity and (ii)
dissection of the arterial wall. Prevented by trial injection of 5
to 10 ml of 45% hypaque to ascertain the position.

Free flush arteriography : here tip of the catheter lies in

aorta. ‘Bolus’ of 30 ml. contrast medium is injected. Series
of X-rays are taken.

Selective angiogram : Tip of the catheter is introduced into

the corresponding artery.
6. Magnetic resonance angiography (MRA):
Advantage :
(iii) Non invasive (ii) Contrast agent is non
nephrotoxic
Limitation :
(v) High cost (ii) Poor availability (iii) Over
estimation of degree of stenosis
⇒ Uses bolus chasing method
⇒ Images are obtained in coronal and sagittal plan
adjustment can be done in bolus dose and time, infusion
rate, region of interest
⇒ Time of flight (TOF) MRA : 2-D and 3-D TOF MRA detect
flow related phenomenon
⇒ Better than contrast enhanced MRA for evaluating
infrapopliteal vessels
Treatment –

2. Abstinence from tobacco

3. Drugs – (ilioprost)

4. Arterial surgery

5. Omental transposition

6. Sympathectomy

7. Neurostimulator devices

8. Gene Therapy

9. Ilizarov technique
1. Abstinence from tobacco – It is only proved treatment
guideline to present disease process. Treatment by any
modality is useless if smoking is continued.
2. Drugs :
(a) Prostaglandins – Prostaglandin I2 (ilioprost) has
antiplatelet and vasodilator activity. Effective in both
cutaneous and muscular vessels. Intraarterial infusion
is done.
Adminished in such a low dose that its effect is
restricted to target area only
Adverse effect is avoided because of extensive
degradation of PG I2 during passage to pulmonary
circulation.
Intraarterial route is effective more than I/V route (15
(b) Dextran –It Cause hemodilution, decrease
blood viscosity and improve microcirculation.
(c) Intraarterial thrombolytic therapy – low
dose streptokinase (1000 U bolus followed by
5000 U/m) can be used but results are
variable.
(d) Praxiline (Niftidrofuryloxalate) – It alter
tissue metabolism, increase claudication
distance by allowing a greater O2 supply to
tissue no proved benefit.
(e) Trental (oxypentifylline) – It has effect on
whole blood viscosity by reducing rouleax
formation. No proven benefit
 Arterial surgery (I) Surgical bypass or
revascularisation
Various by pass procedures are attempted but none
of them is convincing
(a) Direct arterial reconstruction – Some time it is
feasible inspite of multiple occluded distal arteries, if
successful it provides the most effective healing of
ischemic lesion.
(b) If involvement of artery is above knee, by pass
surgery may be possible
Synthetic graft are employed for aorto or ileo femoral
by passes while autologus vein is graft of choice for
infrainguinal bypass
(II) AV fistula –: If there is arterial involvement only
with little pathology in veins. Arterialisation of veins by
creating av fistula between artery proximal to site of
block and adjacent veins
Omental transposition

Pedical omental graft transfer can be used here

because of its tremendous angiogenic properties.

Omental pedical is based on right gastroepiploic

artery (as it has longer length). For bilateral
procedure both epiploics are used. A subfacial
tunnel is made from inferior end of laparotomy
incision to inguinal and further down to ankle
medially. Omentum is lengthened and brought
down to distal most portion of affected limb
through subcutaneous tunnel.
Improvement –
- Ulcer healing
- Rest pain
- Claudication distance
Complication -
- Gastric devascularisation and necrosis in
bilateral cases
- Palalytic ileus
- Gastrichaemorrhage
- Omental necrosis and wound infection
Sympathectomy
It causes -
- Vasodilation
- Increase blood flow to skin and
subcutaneous tissue
- Healing of superficial ischemic ulceration
- Abolish rest pain
It is not beneficial in intermittent claudication
Types (a) Surgical (b) Chemical
Surgical Sympathectomy : lumbar sympathectomy
is done by extraperitoneal approach. L1L2L3 and
sometimes L4 symp ganglion is resected.
Complication – Paralytic ileus, injury to
genitofemoral nerve, ureteric injury, Injury to major
vessel (aorta, IVC), bowel injury.
Laproscopic sympathecomy :It is being used
recently. Here denervation is accomplished by
endoscopic surgical retroperitoneal approach
Advantage : (i) Much less operative trauma
(ii) Less morbidity
(iii) Less chance of complication
Chemical sympathectomy : Fluroscopic or
ultrasound guided injection of 5 ml of 6.7% phenol
is done by retroperitoneal route at L3L4 level and
require no anesthesia.
- Effects are temporary
Percutaneous chemical LS with alcohol with CT
control- It is under evaluation and seems to be
better than traditional chemical L-S.
Side effects :
(I) Injury to surrounding structures by needle
(II) Post sympathetic neuralgia
Radiofrequency denervation : A new percutaneous
approach for sympathectomy using radiofrequency
as denervation source, have less post sympathetic
neuralgia.
Neurostimulator devices : spinal cord
stimulator are : neurostimulator device used
for pain management. They modify electrical
nerve activety. Limitations of these devices
are :
-Data based on randomized control trials
not available
-Can be safely useful only in selected group
of patients
-Lack of sufficient information
Principles : Based on gate control theory of
pain which explain the physiology of pain in
terms of electrical conduction across nerve
synapses, based on ionic changes in CM
and spaces between nerve cells. The flow of
nerve impulse from peripheral to central
nervous system is regulated by cells in
dorsalhorn of spinal cord. The location and
type of ionic activity either open or close the
pain gate.
Patient selection – Used as late treatment from
chronic pain. Used only after other treatment
modalities like pharmacological, surgical, physical,
psychological have been tried.
Procedure – Firstly Demonstration of pain relief
with temporary implanted electrod is made.
optimal electrod placement and pain response to
various frequency is determined. A device is
implanted by placing a multiple electrod lead in
epidural space along the spinal column using a
Tuohy needle. Some times a small laminectomy is
performed to insert a paddle type lead. After
implantation a handheld programmer control
various leads of stimulation.
Safety and efficacy : More effective in neuropathic
pain rather than visceral/ muscular pain.
Provide a major benefit for lesion improvement is
end stage patients. Patient having Tc PO2 > 10 mg
(transcutaneous O2 (pressure) respond better.
Improves ulcer healing and pain relief. Limb
salvage not improved.
Complication of SCS :
Infection in 3-5%
Burning sensation at implantation site
Spasm
Urinary hesitancy
Gene Therapy :
Useful in persistent pain and ischemic
ulcers.
Based on hypothesis that sufficient
exposure of vascular bed to an angiogenic
protein will stimulate neovascularisation. It
ensure continuous expression of angiogenic
protein and prolonged exposure is targeted
vascular bed.
Various angiogenic factors can be used
Such as VEGF, HGF1 del-1 etc.
Gene therapy :
VEGF - Most widely used. Stimulate collateral circulation. It
is DNA fragment can be deposited on arterial wall. The
hydrogel balloon operates like an angioplasty balloon
covered with a hydrophillic layer which delivers the DNA
fragment when inflated. A single intrarterial bolus of VEGF
recombinant human protein result in angiographic,
hemodynamic, physiologic and histological evident
augmentation of collateral circulation more recently I/M route
has been used to take advantage of vascular distribution of
this angiogenic cytokine. The peripheral muscle cells can
perform the transcription and translation into human DNA
protein.
Indication – Can be used in –
Rest pain Ischemic ulcer Intermittent claudication
Hepatocyte growth factor – Potent angiogenic
I/M infusion of naked HGF plasmid DNA is performed in
ischemic limb.
Advantage – Severe complication and adverse side effect of
gene transfer are absent.
Effects :
(1) Reduction of pain related symptom
(2) Increase in angle pressure index more than .1
(3) Diameter of ischemic ulcer reduced.
Can be sole therapy for chronic limb ishcemia in future.
(c) Extracellular matrix protein Del-1
The ECM protein Del-1 is ECM protein that accumulate
around angiogenic vessel and promote angiogenesis.
restore muscle function. It bind to integrin alphabeta 5 on
resting endothelium, convert in to angiogenic endothelium by
inducing expression of proangiogenic molecules integrin
alpha B3.
Ilizarov Technique :- The physiological
basis is the law of Tension Stress. When
living tissue are subjected to uniform
planar distraction force after atraumatic
corticotomy, in the presence in intact
functions, new tissue regenerate in the
limb. Not only does the new bone forms,
but blood vessels, nerves, muscles, fascia
and skin form as well. Thus, it is the
phenomena of distruction
neohistogenesis.
There is increase in the formation of

capillaries in the zone of the ‘Regenerate

Bone Formation’ and in rest of the limb by

an increase in the collateral circulation.

OPERATIVE TECHNIQUE
-Widening of the bone is performed not lengthening.
-Longitudinal osteotomy is performed In the upper part of
the tibia.
-Osteotomy is very slowly distracted apart.
-Gap would fill up with regenerative tissue (bone and
vascular tissue).
Consists of two rings. One in each metaphysis.
Connected with a long rod. Longitudinal osteotomy is
made on the anteromedial face. Triangular fragment is
about 12 to 15 cm long. The osteotomies have a width of
only mm. Periosteum is not damaged.
Distraction done with the help of olive wires or
crossed plain wires at the rate of about 0.25 mm, three to
four times a day.
OLIVE WIRE METHOD
• Olive wires are drilled in from the antero-
lateral crest of the tibia, passing through the
triangular fragment to exit from the postero-
medial corner and the skin.
• Olive to pass through the holes. They rests
against the inner cortex of the triangular
fragment.
• Olive wires connected to a long steel plate.
This steel.
• When the nuts are turned, triangular
fragment widened.
The Modified Crossed Wire Technique
•Achieves horizontal distraction simply and atraumatically.
• Plain K wires are inserted through the postero-medial
aspect into the triangular fragment.
• Four wires are inserted, angulated anteriorly to the mid-
coronal plane. 4 wires are inserted in a plane angled
slightly posterior to the mid-coronal.
• Wires stop within the triangular fragment.
• All the wires are connected to individual bolts and
attached to a steel plate.
• Wires do not cross physically, the resultant vector of
wires pull the triangular fragment horizontally.
• Advantage : No olive wires are needed, no incisions or
predrilling is required for insertion and removal, and the
procedure is simple and atraumatic.
Rate And Rhythm Of Distraction
The ideal rate of distraction (widening)
is one mm per day in fractions of ¼ mm 4
times a day. It the entire 1 mm per day
distraction is done in one step, the bone
formation may be poor. The lesser the range
and more frequent the rhythm, better is the
bone and vessel formation.
POSTOERATIVE COURSE
Full weight bearing possible within a few
days. Total distraction is 1.5 to 2 cm. This much
volume of ‘regenerate bone’ is sufficient to
increase vascularity of the.
The pain relief and appearance of warmth
commences after 15 to 20 days (coincides with the
formation of new blood vessels). The Ilizarov
apparatus is retained on the limb until the
regenerate bone matures and hardens which is
usually 2.5 to 3 months.
RESULTS
• Dramatic pain relief
• Increased Claudication distance
• Limitation of gangreneous spread